Month: September 2013

I recently read this article by Eric Cassell for a course in medical school. What follows are some reflections on the article (here is another link if the other doesn’t work).

Cassell’s essay on suffering broadened my thoughts on what constitutes suffering. Previously I had thought of suffering in a very visceral sense, mostly related to pain. I did consider emotional pain as well as physical pain to be suffering. This would include grief, the pain of an injury or illness or the loss of a relationship. Cassell’s simple definition of suffering made me realize how limited my view was. He states, “I believe suffering to be the distress brought about by the actual or perceived impending threat to the integrity or continued existence of the whole person.” While this definition is brief, a thorough examination leaves a lot of unpacking to do. And while it includes my previous thoughts on suffering it clearly involves much more.

The key phrase for me in the definition is “whole person.” The idea of the self as more than a physical body allows for suffering to be perceived in a variety of ways. Cassell’s expansion on self-identity clarifies this idea further. He talks about the idea of a person’s past, present and future identity. When I think of someone with a disabling injury, while thinking of their suffering I may have only considered their pain and perhaps the limitation on their activities. With Cassell’s framework I can expand this to understand that this person may be suffering from their loss of identity. The things they were able to do in the past, they may no longer be able to do in the present or the future. Beyond the day to day limitations on daily activity it could also present as a serious threat to a person’s sense of self. An elderly person who gardens for example, may have to accept that due to new limitations they can no longer identify themselves as a gardener. If they are able to find a restricted way to garden they at least have to modify what kind of gardener they understand themselves to be.

Considering suffering that is the result of their own actions may reveal why shame and guilt are such powerful emotions. Perhaps someone has made decisions that threaten their existence or sense of self. Not only are they mourning the suffering caused but they are also mourning the fact that they brought the suffering on themselves.

What I appreciate about this more inclusive definition of suffering is how it helps me be more compassionate. I could see myself brushing off certain things someone may tell me as not that big of a deal, but considered in the “whole person” concept of suffering it becomes a big deal and reveals perhaps why this person thinks it is important to talk to me about it. The idea of a “perceived” threat to self helps us to be more compassionate for psychiatric patients whose threat is not reality. Or for parents with a sick child who jump to the worst conclusions possible. Their perception of the threat to their child may not be reality for a pediatrician, but it is a possible reality in their minds. This allows us to not only be understanding but the take the next step and educate in a compassionate way that acknowledges and addresses their fears.

At times in my clinical experience I have been nervous or shy around someone who was clearly suffering. Thinking about all the different types of suffering allows us to be more creative in alleviating suffering. Instead of being frustrated by not being able to completely relieve pain, we can make effort to alleviate other forms of suffering the pain is causing such as loss of function or stress on relationships. When approaching a patient I think I can ask myself a few simple questions. How is this patient suffering? Is there any possible perceived or actual threat to this person’s self-identity? If I am unable to relieve one kind of suffering, am I able to relieve a less obvious form of suffering in this person? I think addressing these questions in all my patients will make me a more complete and compassionate healer.

“What did you use on the floors?” This is a common question I have been getting recently from the recent third year medical students. Third year is a great time to begin building your “peripheral brain” – the pocket references and device apps you use to quickly look things up on the floors. Of course, your own personal preferences will depend on things like specialty interest, how much you want to spend, what do you have available, etc. If you want to use technology some things may be device dependent but in general there is a lot of overlap between Apple and Android apps available. I also used to have a Blackberry Torch and had some apps on there so perhaps there is good news for any holdouts out there. Here’s what I ended up using this year:

At my school, the fourth-year class usually presents this as a gift to the new third-year students and I have some other schools doing this as well. Don’t worry if you can’t get this for free – it is dirt cheap. Really, there is no reason not to have this book. It’s a lifesaver for everything a student or resident needs to do from writing orders to the mini-mental status exam.

This may be more relevant for those interested in internal medicine but there are also similar books for other specialties. I also used the Pocket Pediatrics book. I liked these books because of the charts and algorithms presented. References for primary literature are also provided which can be useful if your attending asks you to look up the article for that particular recommendation. Another nice feature is that these books are in binders which you can open up and add your own pages. A common alternative I have seen others use is the Washington Manual of Medical Therapeutics.

Device Apps

Medscape

This is a free app and all you need is a Medscape username and password. Although not quite as good as Up-to-Date it is fairly complete and well-organized. For most diseases it will have labeled sections on diagnosis, work-up, and treatment or management. It also includes its own drug monograph database and a host of calculator tools such as Ranson criteria or Centor. The one drawback is that it is not as searchable as I would like. For example, you cannot search for the aforementioned criteria as Ranson or Centor. You have to look for “pancreatitis prognosis” or “strep throat evaluation”. However, usually the search pulls a list as you are typing so you will likely find what you are looking for before you even completely type in a word.

AHRQ ePSS

This stands for Agency on Healthcare Research and Quality Electronic Preventative Services Selector. This app is essential for a rotation with a primary care component (e.g. outpatient medicine, family medicine). You type in the patient demographic data including gender, age, smoking status, and sexual activity and it pulls the current USPSTF recommendations for preventative services that patient should or should not be receiving.

ePocrates

This was my preferred drug monograph database during third year. It has a nice interaction checker, calculators, reference tables, and more. There are others like Micromedex and the one on Medscape. Whatever you do, have one and understand how it works.

I actually am ambivalent on this book. For future surgeons, it may be more appropriate. I found it useful to a point but it had only decent yield for “pimping” and was not quite appropriate for the NBME shelf exam.

I am not sure if all medical students will still be working with DSM-IV but either have a pocket reference (check if your school provides one) or download an app. Learning the specific criteria is particularly high yield for a psychiatry rotation and standardized tests.

Final Thoughts

Whatever you decide to use for your peripheral brain make sure you keep it tight to a select few resources and know how to find the information in each. It does you no good to be overloaded with tools and spending too much time figuring them out while you need information. Take some time on a weekend to really play with your tools and familiarize yourself with them.